Surgical Management of Malignant Intestinal Obstruction: Outcome and Prognostic Factors

Palliative procedures for advanced obstructive colorectal cancer: a systematic review and meta-analysis

PURPOSE

Advanced obstructive colorectal cancer (AOCC) presents surgical challenges. Consideration must be given to alleviating symptoms and also quality of life and survival time. This study compared prognostic efficacies of palliative self-expanding metal stents (SEMSs) and surgery to provide insights into AOCC treatment.

METHODS

PubMed, Web of Science, MEDLINE, and Cochrane Library were searched for studies that met inclusion criteria. Using a meta-analysis approach, postoperative complications, survival rates, and other prognostic indicators were compared between patients treated with SEMSs and those treated surgically. Network meta-analysis was performed to compare prognoses between SEMS, primary tumor resection (PTR), and stoma/bypass (S/B).

RESULTS

Twenty-one studies were selected (1754 patients). The odds ratio (OR) of SEMS for clinical success compared with surgery was 0.32 (95% confidence interval [CI] 0.15, 0.65). The ORs for early and late complications were 0.34 (95% CI 0.19, 0.59) and 2.30 (95% CI 1.22, 4.36), respectively. The ORs for 30-day mortality and stoma formation were 0.65 (95% CI 0.42, 1.01) and 0.11 (95% CI 0.05, 0.22), respectively. Standardized mean difference in hospital stay was - 2.08 (95% CI - 3.56, 0.59). The hazard ratio for overall survival was 1.24 (95% CI 1.08, 1.42). Network meta-analysis revealed that SEMS had the lowest incidence of early complications and rate of stoma formation and the shortest hospital stay. PTR ranked first in clinical success rate and had the lowest late-complication rate. The S/B group exhibited the lowest 30-day mortality rate.

CONCLUSION

Among palliative treatments for AOCC, SEMSs had lower early complication, stoma formation, and 30-day mortality rates and shorter hospital stays. Surgery had higher clinical success and overall survival rates and lower incidence of late complications. Patient condition/preferences should be considered when selecting AOCC treatment.

Management of obstructed colorectal carcinoma in an emergency setting: An update

Colorectal carcinoma is common, particularly on the left side. In 20% of patients, obstruction and ileus may be the first clinical manifestations of a carcinoma that has advanced (stage II, III or even IV). Diagnosis is based on clinical presentation, plain abdominal radiogram, computed tomography (CT), CT colonography and positron emission tomography/CT. The best management strategy in terms of short-term operative or interventional and long-term oncological outcomes remains unknown. For the most common left-sided obstruction, the first choice should be either emergency surgery or endoscopic decompression by self-expendable metal stents or tubes. The operative plan should be either one-stage or two-stage resection. One-stage resection with on-table bowel decompression and irrigation can be accompanied or not accompanied by proximal defunctioning stoma (colostomy or ileostomy). Primary anastomosis is more convenient but has increased risks of anastomotic leakage and morbidity. Two-stage resection (Hartmann's procedure) is safer and the most widely used despite temporally affecting quality of life. Damage control surgery in high-risk frail patients is less frequently performed since it can be successfully substituted with endoscopic stenting or tubing. For the less common right-sided obstruction, one-stage surgical resection is more beneficial than endoscopic decompression. The role of minimally invasive surgery (laparoscopic or robotic) is a subject of debate. Emergency laparoscopic-assisted management is advantageous to some extent but requires much expertise due to inherent difficulties in dissecting the distended colon and the risk of rupture and subsequent septic complications. The decompressing stent as a bridge to elective surgery more substantially decreases the risks of morbidity and mortality than emergency surgery for decompression and has equivalent medium-term overall survival and disease-free survival rates. Its combination with neoadjuvant chemotherapy or radiation may have a positive effect on long-term oncological outcomes. Management plans are crucial and must be individualized to better fit each case.

Observation of the Effect of Focused Psychological Intervention Combined with Standardized Pain Nursing on Postoperative Pain Levels and Depression and Anxiety in Patients with Intestinal Obstruction

Objective

The purpose of this study was to investigate the effect of targeted psychological intervention combined with standardized pain care on postoperative pain, depression, and anxiety in patients with intestinal obstruction.

Methods

84 patients with intestinal obstruction hospitalized at our hospital from October 2019 to February 2021 were randomly divided into study and control groups. The patients in the control group were treated with routine nursing, and the patients in the study group were treated with focused psychological intervention combined with standardized pain nursing. The pain degree (VAS), depression and anxiety (SDS, SAS) score, sleep quality (PSQI) score, and nursing satisfaction of the two groups before and after intervention were calculated.

Results

Before intervention, no significant differences in VAS score between the study and control groups were observed. The VAS score of 6 h, 12 h, 24 h, and 48 h dry prognosis in the study group was lower than that in the control group. There was no significant difference in the scores of SDS and SAS between two groups. After intervention, the scores of SDS and SAS in the study group were lower than those in the control group. After intervention, the scores of daytime dysfunction, hypnotic drugs, sleep disorders, sleep efficiency, sleep time, and sleep quality in the study group were significantly lower than those in the control group. The scores of nursing state, nursing technique, nurse-patient communication, and inspection observation in the study group were higher than those in the control.

Conclusion

The intervention of focused psychological intervention combined with standardized pain nursing on patients with intestinal obstruction can effectively relieve their negative emotion and reduce the degree of postoperative pain. In addition, it can improve patients' sleep quality and enhance patients' satisfaction with all kinds of nursing work.

A Palliative Approach to Management of Peritoneal Carcinomatosis and Malignant Ascites

In addition to severe, life-limiting complications such as malignant bowel obstruction, fistulae, and malignant ascites, peritoneal carcinomatosis frequently causes life-impacting symptoms such as pain, nausea, anorexia, cachexia, and fatigue. A variety of medical, interventional, and surgical therapies are now available for management of both complications and symptoms. Although surgery in this population is often associated with a relatively high risk of morbidity and mortality, operative intervention can offer effective palliative treatment in appropriately selected patients. Early involvement of palliative care specialists as part of a multidisciplinary team is essential to providing optimal, holistic care of patients with peritoneal carcinomatosis.

Current management of malignant bowel obstructions: a survey of acute care surgeons and surgical oncologists

Background

Malignant small bowel obstructions (MSBOs) are one of the most challenging problems surgeons encounter, and evidence-based treatment recommendations are lacking. We hypothesized that current opinions on MSBO management differ between acute care surgeons (ACSs) and surgical oncologists (SOs).

Methods

We developed three case scenarios describing patients with previously treated cancer who developed an MSBO. Each case had five to six alternate scenarios, intended to capture the heterogeneity of MSBO presentations. Members of the Society of Surgical Oncology, the American Society of Peritoneal Surface Malignancies, and the Eastern Association for the Surgery of Trauma were asked how likely they would be to offer surgical treatment in each scenario. Responses were analyzed for factors associated with the likelihood surgeons would offer surgical management.

Results

316 surgeons completed the survey: 119 (37.7%) SOs and 197 (62.3%) ACSs. Overall, SOs were nearly twice as likely as ACSs to recommend surgical management. The largest differences between provider groups were seen in patients with an increased metastatic burden. In a patient with MSBO with metastatic colon cancer, both SOs (95.8%) and ACSs (94.4%) were likely or very likely to offer an operation (p=0.587); however, this fell to 91.6% and 77.7%, respectively, when this patient had multiple hepatic metastases (p=0.001). All surgeons were less likely to offer surgery to patients with multiple sites of obstruction, recurrent MSBO, and shorter disease-free intervals.

Discussion

Opinions on MSBO management differ based on surgeon training and experience. Multidisciplinary management of patients with MSBO should be offered when available and increased emphasis placed on determining optimal management guidelines across specialties.

Level of evidence

Level IV Epidemiologic.

Surgical and Conservative Management of Malignant Bowel Obstruction: Outcome and Prognostic Factors

Purpose

Malignant bowel obstruction (MBO) is a common problem in late-stage cancer patients. Many factors are suggested to be associated with the prognosis of MBO. The current investigation was designed to explore the factors associated with the prognosis of conservative and surgery treatment in one single institution.

Patients and Methods

Sixty-four patients of MBO were recruited into the study. Demographic and clinical data including gender, age, primary cancer, radiological and laboratory examinations, and nutritional and pain index scaling were extracted for further analysis. Kaplan-Meier analysis and logistic regression analysis were used to compare the prognosis and detect significant factors.

Results

Of the 64 patients, there is no statistical difference in baseline features between conservative and surgical group. However, the length of stay, total medical costs, re-admission interval, and re-admission rate are statistically significant. There is no significance in Kaplan-Meier log rank test for median survival time, though the overall survival time in the conservative group is longer than that of the surgery group. Logistic regression analysis has found that prior chemotherapy is a significant predictor for final survival outcome.

Conclusion

The election of surgery might not improve the overall survival time. Non-surgical procedures, especially chemotherapy, might be preferable for MBO patients.

Surgical intervention for malignant bowel obstruction caused by gastrointestinal malignancies

BACKGROUND

Malignant bowel obstruction (MBO) is a common event for end-stage gastrointestinal cancer patients. Previous studies had demonstrated manifestations and clinical management of MBO with mixed malignancies. There still lack reports of the surgical treatment of MBO.

AIM

To analyze the short-term outcomes and prognosis of palliative surgery for MBO caused by gastrointestinal cancer.

METHODS

A retrospective chart review of 61 patients received palliative surgery between January 2016 to October 2018 was performed, of which 31 patients underwent massive debulking surgery (MDS) and 30 underwent ostomy/by-pass surgery (OBS). The 60-d symptom palliation rate, 30-d morbidity and mortality, and overall survival rates were compared between the two groups.

RESULTS

The overall symptom palliation rate was 75.4% (46/61); patients in the MDS group had significantly higher symptom palliation rate than OBS group (90% vs 61.2%, P = 0.016). Patients with colorectal cancer who were in the MDS group showed significantly higher symptom improvement rates compared to the OBS group (overall, 76.4%; MDS, 61.5%; OBS, 92%; P = 0.019). However, patients with gastric cancer did not show a significant difference in symptom palliation rate between the MDS and OBS groups (OBS, 60%; MDS, 80%; P = 1.0). The median survival time in the MDS group was significantly longer than in the OBS group (10.9 mo vs 5.3 mo, P = 0.05).

CONCLUSION

For patients with MBO caused by peritoneal metastatic colorectal cancer, MDS can improve symptom palliation rates and prolong survival, without increasing mortality and morbidity rates.